This blog follows the history of psychiatry

DSM-V: Getting Closer to Pathologizing Everyone?

For several years, the discussions about the deliberations of the various task forces involved in constructing the latest revision of the Diagnostic and Statistical Manual of the American Psychiatric Association, the DSM-V, have been shrouded in secrecy. The lack of transparency of the discussions generated highly publicized criticisms from such luminaries as Robert Spitzer, the major developer of the revolutionary DSM-III, and Allen Frances, chair of the DSM-IV task force. This situation radically changed in February with the release of the revisions of the changes proposed by the 13 work groups charged with revising the DSM.

Most of the public response to the proposed changes has centered on several alterations to particular diagnostic categories. The suggestions include using a new diagnosis of “temper dysregulation with dysphoria” for children instead of bipolar disorder, incorporating Asperger’s disorder, autistic disorder, and several other conditions into a single “autism spectrum disorders” category, and recognizing some new types of eating disorders. The focus on these specific changes, most of which are sensible, has deflected attention away from other suggestions that have much greater potential import.

Three changes, in particular, could lead to an enormous pathologization of non-disordered conditions. The first is the suggested revision of the criteria for Major Depressive Episode to remove the bereavement exclusion from this diagnosis. At present, the criteria for major depression require five or more out of nine symptoms including sadness or lack of interest or pleasure that least for at least two weeks. However, the criteria exclude people who experience these symptoms in response to bereavement: “The symptoms are not better accounted for by Bereavement” That is, people who develop enough symptoms to meet the criteria after the death of an intimate are nevertheless not defined as disordered but instead as suffering from a natural, nondisordered response to loss.

The reason for the bereavement exclusion is obvious. Voluminous evidence indicates that bereavement after the loss of an intimate is a natural reaction. The earliest literary portrayals of human experience such as Gilgamesh and The Iliad indicate that grief is a basic human emotion. Likewise, while different cultures have vastly different expressions of grief, sadness and accompanying psychological and somatic symptoms after the loss of a loved one is a universal experience. Even many primates show demonstrable signs of depression-like symptoms after the death of a close relation. In the vast majority of cases, the universal symptoms of grief dissipate with the passage of time and only a minority of the bereaved remains highly symptomatic after several months pass.

If the suggested revision is implemented anyone who is sad, fails to derive pleasure from usual activities, finds it difficult to concentrate, and has sleep and appetite difficulties for a mere two weeks could be diagnosed with Major Depressive Disorder. Because virtually the entire population will be bereaved at some point in their lives and because such a high proportion of the bereaved would meet diagnostic criteria that require two week duration, this proposal could pathologize an enormous number of people.

A second proposal that has the promise of massively medicalizing natural emotions is to adapt dimensional assessments for the existing categorical diagnoses. On the surface, this proposal sounds sensible and desirable. Major Depression, for example, requires the presence of five symptoms but there is no natural cut-off point between four and five symptoms, or at any other particular point for this diagnosis. Depression, as well as the other major conditions in the DSM, seems to naturally be a continuous rather than a categorical condition.

The problem in dimensionalizing common conditions such as depression and anxiety is that a small number of “subthreshold” symptoms typically indicate a non-disordered condition, not a milder form of disorder. The only way to accurately use a dimensional system is to initially use criteria for disorder that separates natural from disordered conditions, regardless of how many symptoms are present. If adequate conceptions of disorder first distinguish contextually appropriate symptoms that are commonly transitory responses to stressors from mental disorders, then dimensional measurement could represent a distinct improvement in the DSM. As the discussion of bereavement indicates, however, the separation of disorders from non-disorders in the DSM-V seems to be getting worse rather than better. The current proposal to dimensionalize measures of frequently occurring disorders threatens to pathologize even mildly distressing conditions. While potentially valuable, it needs reconsideration and reformulation.

A final worrisome proposal lies in the creation of “at-risk” categories for mental disorder. At present, this possible category is limited to psychotic conditions; people who have just one symptom from among delusions, hallucinations, and disorganized speech who have never met the criteria for a psychotic disorder could receive the “at-risk” diagnosis. The diagnosis is well-intentioned and aimed at identifying people who might be at an early stage of a psychotic condition but who don’t yet meet the full criteria. Such people might benefit from early identification and treatment.

The problem with the “at-risk” category is it’s potential as a Trojan horse that would diagnose nearly a-symptomatic people as being in the early stages of a disorder. Yet, at present, there is no way of knowing which people with a single or a small number of symptoms will go on to meet the full diagnostic criteria and which will not. The latter group will typically outnumber the former group so that the potential for false positive diagnoses is enormous.

The current suggested revision only applies to psychotic conditions where it might not create too much damage. If it were applied to widely occurring conditions such as depression and anxiety, however, the result could be a massive amount of new pathology. For example, one of the best known studies of depression, the Dunedin Study, ties the presence of the small allele of the 5-HT gene to this condition. Yet, nearly 20% of people have two copies of the small allele and over half have one copy, so over two-thirds of the population could be viewed as “at-risk” for developing depression . Once a gene is identified as a risk factor for depression, anyone who has the gene may be a candidate for intervention, even if they don’t actually have a depressive condition. Genetic tests could identify “at risk” individuals, who could then be placed on long-term regimes of drug therapies. In the case of the 5-HT gene, a majority of people would be at risk for depression. While the DSM-V working groups have not (yet) proposed an at-risk category for depression or any other commonly occurring condition, this danger might be lurking in the future.

Overall, it appears that the original promise of the DSM-III in 1980 – the creation of a clear, precise, and reliable diagnostic system that would eventually lead to more accurate knowledge about the causes, prognoses, and treatments of mental disorders has not been fulfilled. Indeed, it is difficult to think of a single breakthrough that has resulted from psychiatry’s classificatory system. The major proposals in the DSM-V do not seem as if they will change this situation and could wind up making psychiatry’s central problem of distinguishing pathology from normality even more difficult to resolve.

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Yes, that’s my image. I am always a tiny startled when I see it online. Thanks for identifying me. I’ve joined this list. And, I wonder what the next photo is going to look like. How big will the volume be? BTW, I once had, but somehow lost, a copy of DSM-I. If I ever get a copy, I’ll reshoot the comparison image.

Dr Frances was the chair of the DSM-IV Task Force and of the department of psychiatry at Duke University School of Medicine, Durham, NC. He is currently professor emeritus at Duke.

I have previously criticized the DSM5 process—for its unnecessary secretiveness, its risky ambitions, its disorganized methods, and its unrealistic deadlines.1-6 Now, it is finally time to evaluate the first draft of the recently posted DSM5 product (at http://www.DSM5.org).

Poor and inconsistent writing

Perhaps it should occasion no surprise that a flawed process should yield a flawed product. The most fundamental problem is the poor and inconsistent writing. Admittedly, early Work Group drafts are often written imprecisely and with varying quality, but it is surprising that the DSM5 leadership has failed to edit for clarity and consistency. It would be a waste of effort, time, and money to conduct field trials before the new criteria sets receive extensive revision. The poor writing is also a bad prognostic sign, suggesting that the DSM5 text sections for the various disorders may eventually be equally inconsistent, variable in quality, and sometimes incoherent.

Higher rates of mental disorder

In terms of content, most concerning are the many suggestions for DSM5 that would dramatically raise the rates of mental disorder. These come in 2 forms:

1. New diagnoses that would be extremely common in the general population (especially after marketing by an ever alert pharmaceutical industry)

2. Lowered diagnostic thresholds for many of the existing disorders.

DSM5 would create tens of millions of newly misidentified false positive “patients,” thus greatly exacerbating the problems caused already by an overly inclusive DSM4.7 There would be massive overtreatment with medications that are unnecessary, expensive, and often quite harmful. DSM5 appears to be promoting what we have most feared–the inclusion of many normal variants under the rubric of mental illness, with the result that the core concept of “mental disorder” is greatly undermined.

Unforeseen consequences

A third pervasive weakness in the DSM5 options is their insensitivity to possible misuse in forensic settings. Work Group members cannot be expected to anticipate the many ways lawyers will try to twist their good intentions, but it is incumbent on the DSM5 leadership to establish a thorough ongoing forensic review that would identify the many likely instances of proposals with important forensic implications (for example, the expansion of pedophilia to include attraction to adolescents).

Space constraints (as well as my own blind spots and limitations in expertise) make this a limited survey, both in the numbers of issues discussed and the depth of discussion possible on each. I would encourage the field to identify the additional problems that will require correction.

PROBLEMATIC NEW DIAGNOSES

The Psychosis Risk Syndrome is certainly the most worrisome of all the suggestions made for DSM5. The false positive rate would be alarming—70% to 75% in the most careful studies and likely to be much higher once the diagnosis is official, in general use, and becomes a target for drug companies.8 Hundreds of thousands of teenagers and young adults (especially, it turns out, those on Medicaid) would receive the unnecessary prescription of atypical antipsychotic drugs.9 There is no proof that the atypical antipsychotics prevent psychotic episodes, but they do most certainly cause large and rapid weight gains (see the recent FDA warning) and are associated with reduced life expectancy—to say nothing about their high cost, other side effects, and stigma.

This suggestion could lead to a public health catastrophe and no field trial could possibly justify its inclusion as an official diagnosis. The attempt at early identification and treatment of at risk individuals is well meaning, but dangerously premature. We must wait until there is a specific diagnostic test and a safe treatment.

Mixed Anxiety Depressive Disorder taps nonspecific symptoms that are widely distributed in the general population and would therefore immediately become one of the most common of all the mental disorders in DSM5. Naturally, its rapid rise to epidemic proportions would be ably assisted by pharmaceutical marketing. It is likely that medication would not be much more effective than placebo because of the high placebo response rates in milder disorders.10

Minor Neurocognitive Disorder is defined by nonspecific symptoms of reduced cognitive performance that are very common (perhaps almost ubiquitous) in people over fifty. To protect against false positives, there is a criterion that requires objective cognitive assessment to confirm that the individual has decreased cognitive performance, but getting a meaningful reference point is impossible in most instances and the threshold has been set to include a whopping 13.5% of the population (ie, the percent of population within the first and second standard deviation). Moreover, the suggestion for objective testing will probably be widely ignored in the primary care settings where the bulk of diagnosing will be done.

Medicalizing the expectable cognitive impairments of aging will result in much unnecessary treatment with ineffective prescription drugs and quack folk remedies. These will undoubtedly attain great popularity since there will likely be a very high placebo response rate.

Binge Eating Disorder will have a rate in the general population (estimated at 6%) and this will probably become much higher when the diagnosis becomes popular and is made in primary care settings. The tens of millions of people who binge eat once a week for 3 months would suddenly have a “mental disorder”— subjecting them to stigma and medications with unproven efficacy.

Temper Dysfunctional Disorder with Dysphoria is one of the most dangerous and poorly conceived suggestions for DSM5—a misguided medicalization of temper outbursts. The “diagnosis” would be very common at every age in the general population and would promote a large expansion in the use of antipsychotic medications, with all of the serious attendant risks described above. Apparently, the Work Group was trying to correct excessive diagnosis of childhood bipolar disorder—but its suggestion is so poorly written that it could not possibly accomplish this goal and instead would it would create a new monster.

The misapplication of this diagnosis would provide a blanket excuse for reduced personal responsibility and will lead to forensic nightmares. It is a nonstarter.

Paraphilic Coercive Disorder would expand the pool of sex offenders who are eligible for indefinite civil commitment because they have a “mental disorder” to include cases of sexual coercion. Paraphilic Coercive Disorder was initially considered for inclusion in DSM-III-R (under the name Paraphilic Rapism) but was rejected because it was impossible to reliably and validly differentiate those rapists whose actions are the result of a paraphilia from the large majority of rapists who are motivated by other factors (such as power). Given the facts (acknowledged in the rationale section) that most rapists are savvy enough to deny sexual fantasies and the unreliability (and unavailability) of laboratory testing, the diagnosis will inevitably be based only on the person’s behavior, leading to a potentially alarming rate of false positives with consequent wrongful indefinite commitment.11

Hypersexuality Disorder would be a gift to false positive excuse seekers and potential forensic disaster. Another clear nonstarter.

A Behavioral Addictions category would be included with the substance addictions section and would start life with one disorder, Pathological Gambling (transferred from Impulse Disorders section). Next in line might be a new category for Internet Addiction. This could provide a slippery slope leading to the back door inclusion of a variety of silly and potentially harmful diagnoses (ie, “addictions” to shopping, sex, work, credit card debt, videogames etc, etc, etc) under the broad rubric of “behavioral addictions not otherwise specified.” The construct “Behavioral Addictions” represents a medicalization of life choices, provides a ready excuse for off loading personal responsibility, and would likely be misused in forensic settings. LOWERED THRESHOLDS

The greatest general impact would come from the suggestion to eliminate the “clinical significance” criterion required in DSM4 for each disorder that has a fuzzy boundary with normality (about two-thirds of them). These were included to ensure the presence of clinically significant distress or impairment when the symptoms of the disorder in mild form might be compatible with normality. Removing this requirement would reduce the role of clinical judgment as a gatekeeper in determining the presence or absence of mental disorders and thus would increase the already swollen rates of psychiatric diagnosis.

Attention Deficit/Hyperactivity Disorder. The DSM4 wording changes (along with extremely active drug company marketing) contributed to escalating rates of ADD – accompanied by the widespread misuse of stimulant medications for performance enhancement and the emergence of a large secondary illegal market.12 There are 4 suggestions for DSM5 that would make this existing overdiagnosis much worse.

•The first change is to raise the required age of onset from 7 to 12.13

•The second is to allow the diagnosis based only on the presence of symptoms, not requiring impairment.

•The third is to reduce by half the number of symptoms required for adults.

These 3 changes greatly reduce the specificity of the ADD diagnosis in adolescents and adults and will result in a further flood of false positives and of resulting stimulus misuse for performance enhancement.14

•The fourth change is to allow the diagnosis of ADD in the presence of autism. This might create the interaction of 2 false epidemics, encouraging increased stimulant use in an especially vulnerable population.

Addiction Disorder. DSM5 proposes to eliminate the distinction between substance abuse and substance dependence, lowering the threshold for diagnosing the new unified category— “addiction”—that would be introduced to replace them both. This confounding of episodic binge use with continuous compulsive use loses valuable clinical information about their very different treatment and prognostic implications. It also seems unnecessarily stigmatizing and misleading to label with the loaded word addiction those whose problem is restricted to intermittent substance use.

Autism Spectrum Disorder. Asperger’s disorder would be collapsed into this new unified category. Although this consolidation appeals to some experts, it remains controversial and presents serious problems. Those with Asperger’s (which is much less impairing) will be stigmatized by the association with classic autistic disorder. Moreover, in the average everyday practice conducted by non-experts, the spectrum concept will likely further fuel the “epidemic” of loosely defined autism that was already been triggered by the introduction of Asperger’s in DSM4.15

Medicalizing Normal Grief. DSM5 would reverse 30 years of diagnostic practice and allow the diagnosis of Major Depression to be made for individuals whose grief reaction symptomatically resembles a Major Depressive episode (eg, 2 weeks of depressed mood, loss of interest in activities, insomnia, loss of appetite, and trouble concentrating immediately following the loss of a spouse would be a mental disorder. This is radical and astounding change that may be helpful for some individuals, but will cause a huge false positive problem—especially since there is so much individual and cultural variability in bereavement. Of course, grief would become an extremely inviting target for the drug companies.

Pedohebephilia is one of the most poorly written and unworkable of the suggested criteria sets. Expanding the definition of pedophilia to include pubescent teenagers would medicalize criminal behavior and further the previously described misuse of psychiatry by the legal system. Certainly, sex with under-age victims should be discouraged as an important matter of public policy, but this should be accomplished by legal statute and appropriate sentencing, not by mental disorder fiat.

Deleting the Multiaxial System. This would result in the loss of much valuable clinical information. Multi-axial diagnosis provides a disciplined approach to distinguishing between state and trait (Axis I versus Axis II) and to determining the contributions of medical conditions (Axis I II) and of stressors (Axis IV) to the diagnosis and treatment of psychiatric disorders. The GAF score (Axis V) provides the most convenient and familiar rating of overall functioning. No compelling rationale is offered for making so radical a change.

Various Small Changes. There are numerous small editorial changes meant to help clarify the existing criteria sets. Some of these appear to be improvements, many are trivial, and some are worse than their DSM4 counterparts. Any possible gain from wording changes has to be weighed against the risks that the new version will create its own set of unanticipated consequences. The old, tried and true criteria sets have withstood the test of time -in some instances for 30 years-without creating forensic problems. Moreover, even small changes can have a dramatic impact on the definition of caseness and resulting rates of disorder16 needlessly compromising the interpretation of all the clinical and epidemiological research that was done before versus that done after DSM5.

Dimensional Assessments

Three dimensional assessments (for severity, co-morbid symptoms, and personality traits) are suggested for DSM5. Dimensions are most appropriate in describing continuously distributed phenomena that can be reduced to numbers. It has been widely accepted for several decades that adding dimensions would help to solve the categorical system’s problem with fuzzy boundaries- thus improving the accuracy and precision of psychiatric diagnosis.17 Unfortunately, however, the field has never achieved consensus on which dimensions to choose and how best to measure them. Moreover, and most crucial, clinicians find dimensional ratings far too unfamilar and cumbersome for use in everyday practice and all efforts to include even a few simple dimensional ratings into previous DSM’s have been met by clinician resistance and neglect. The DSM5 dimensional proposals are especially problematic—ad hoc, unworkably complex, vague, untested, and premature. If anything, the poorly executed introduction of unwieldy dimensions into DSM5 is likely to give them a bad name and poison the well for their future necessary acceptance. It is also possible that the use of dimensions may create problematic unintended consequences in insurance, disability, and forensic determinations. The possible introduction of dimensions by DSM5 has been greatly oversold as a “paradigm shift.” With a few exceptions, it would probably be advisable to include the suggested dimensional ratings in the DSM5 appendix or in a separate volume for diagnostic instruments.

Severity ratings tailored for each disorder. In fact, this approach was tried for 8 categories in DSM3R, but was dropped in DSM4 because the anchors of the severity ratings were not validated and the system was too cumbersome for routine clinical use. The severity ratings suggested for DSM5 are bewilderingly inconsistent across sections in their format and quality and are largely ad hoc, extremely complicated and totally impractical for use in clinical settings.

Ratings on “crosscutting” symptoms that exist across a number of different diagnoses to supplement the primary categorical diagnosis. Such assessment might be useful in some settings, but is far too cumbersome for use in routine clinical practice.

Dimensional ratings for personality. These would, in theory, have clear advantages over the clumsy categorical approach to personality assessment. In practice, however, the multiple, complicated, confusing, and cumbersome systems suggested for DSM5 would be far too unfamiliar and time consuming to ever be used by clinicians. Another side effect would be deletion of five of the personality disorders (paranoid, narcissistic, histrionic, dependent, schizoid) from the manual.

CONCLUSIONS

It will likely be argued by the DSM5 leadership that I am unduly and prematurely alarmist, that they are still early in the DSM5 process, and that any problematic suggestions will eventually be weeded out in the field trials. This is putting the cart (ie field testing) before the horse (ie having usable criteria sets to test) and continues to miss the point that DSM5 has been and remains in serious trouble. I feel it is my responsibility to raise clear alarms now because the past performance of the DSM5 leadership does not inspire confidence in its future ability to avoid serious mistakes.

What leads me to this pessimistic conclusion? Every step in the development of DSM5 has been secretive and disorganized. The leadership has established a consistent track record of proposing unrealistic plans and impossible to meet timetables—with predictably erratic course changes and repeatedly missed deadlines. It was, for example, announced last May at the APA annual meeting (and in the press) that the DSM5 field trials were about to begin in the summer of 2009. Then, it turned out that none of the necessary preparatory steps had been accomplished and the field trials had to be postponed for at least a year. During the past 6 months, there have been several successive target dates for posting the DSM5 drafts—each of which passed unmet causing unexplained postponements. Poor planning and execution have already forced a 1 year delay in the projected DSM5 publication date (to May 2013).

The DSM5 process is already nearly 3 years old. By now, a careful editing process should have resulted in refined proposals that were all plausible and all clearly and consistently written. Field trials are arduous and expensive and make sense only for testing the precise wording of criteria sets that have a real chance of making it into the manual—not for the many poorly written and far out suggestions that have just been posted. It seems prudent to identify and root out problems now lest they sneak through in what will likely be an eventual mad rush to complete DSM5. My fear remains that left to its own devices and without continued external pressure and assistance, the DSM5 process may never produce a quality product (even with the extended deadline of 2013).

There is, however, one criticism of the DSM5 process that demands a clear rebuttal. It has been alleged that those working on DSM5 have financial and/or professional conflicts of interest which bias them to make decisions that increase the rates of psychiatric diagnoses (ie, to benefit drug companies, or to increase research funding, or to expand the practice opportunities of mental health workers. I know most of the people working on DSM5 and can assure you that this accusation is simply false. They have the highest integrity and are making (what I believe to be often mistaken and sometimes even dangerous) suggestions because they sincerely, but naively, believe that this is where the science is leading them— not for any personal or professional gain.

How can such smart and scrupulous people make so many bad suggestions? It has been my consistent experience (gained working on the previous three DSM’s) that each Work Group always has a strong (and seemingly irresistible) bias for expanding the boundaries of the disorders in its section. This expectable Work Group diagnostic imperialism must always be recognized and resisted. Experts understandably place a high value on reducing false negatives for their favorite disorders and in avoiding the need to resort to the label “not otherwise specified.” They hope in this way to identify patients early in their course and to institute treatments that will be effective in reducing the lifetime burden of illness.

Unfortunately, Work Group members usually have a correspondingly huge blind spot—missing the fact that every effort to reduce the rate of false negatives must inevitably raise the rate of false positives (often dramatically and with dire consequences). It is inherently difficult for experts, with their highly selected research and clinical experiences, to appreciate fully just how poorly their research findings may generalize to everyday practice—especially as it is conducted by harried primary care clinicians in an environment heavily influenced by drug company marketing. They also consistently underestimate the costs and risks of medication treatment when it is given to those who don’t really need it. If we are ever to realize the wished for gains of early case finding, we must first have both specific diagnostic tests and safe and effective treatments. In contrast, the DSM5 suggestions display the peculiarly dangerous combination of nonspecific and inaccurate diagnosis leading to unproven and potentially quite harmful treatments.

I wish to emphasize that the problems in this DSM5 draft are not at all the fault of the Work Group members who have labored hard under very unpromising conditions. The DSM5 options are poorly conceived and executed because of the interaction of 4 unfortunate decisions made by the DSM5 leadership:

1. Requiring unnecessary confidentiality agreements that insulated the Work Groups from the usual and necessary corrective interaction with the field

2. Tightly restricting Advisors to a small and highly selected group

3. Establishing the expectation that Work Groups be innovative rather than risk/benefit conscious

4. Providing the Work Groups with remarkably little guidance, consistency, and editorial assistance.

Because of the secretive and closed nature of the DSM5 process, the expectable enthusiasms of the experts who comprise the Work Groups have not been balanced, as they must always be, with real world practical clinical wisdom and a careful risk/benefit analysis of the possible unintended consequences of every suggestion.

It would be reckless now to rely on the complacent assumption that all these problems will eventually come out in the wash. By its previous actions and inactions, the DSM5 leadership has sacrificed any “benefit of the doubt” faith that their process will be self-correcting in a way that guarantees the eventual elimination all of the harmful options.

There is, however, some cause for measured optimism regarding the future of the DSM5 process based on the fact that it does respond, albeit reluctantly, to external pressure. There have been significant and encouraging improvements during the past several months. A DSM5 Oversight Committee was finally appointed and has played a very beneficial role in correcting the most egregious problems in the previous methods and deadlines. The ill conceived plan to conduct field trials before having a public review of criteria was dropped and the unrealistic field trial and publication deadlines were each extended by a year. The additional time provided by the extended deadlines, if used well, would be sufficient to produce a serviceable DSM5.

What needs to be done next? The responsibility (and opportunity) for rescuing DSM5 falls most heavily on the field at large and on the Oversight Committee. Now that the DSM5 drafts are finally open for wide review, it behooves the field to be active in identifying problems and providing the needed pressure to ensure they will be corrected. My recommendations for the Oversight Committee are:

1. Extend the period allotted for public review to 3 months.

2. Use this time to ensure the careful editing of each word of each item of every criteria set to provide the clarity and consistency that is now sorely lacking and is absolutely necessary before any meaningful field testing can begin.

Every future step in the preparation of DSM5 should involve active interaction with the field and with the Oversight Committee and its subcommittees. Unnecessary secrecy has caused the current problems and only full transparency and openness to outside input will solve them.

I have had the space and expertise to identify only the DSM5 trouble spots that are most obvious to me. The rest is up to you. Please take the time to review the DSM5 options (at least in your areas of interest) and supply your input. They can be found at http://www.dsm5.org.

On the last year’s congress of Society for Bipolar Disorders in Sao Paulo, Br, i heard an information, that the period of elevated mood, necessary to diagnose a Bipolar-spectrum Disorder should be shortened to one day.

It is technically not true that “…anyone who is sad, fails to derive pleasure from usual activities, finds it difficult to concentrate, and has sleep and appetite difficulties for a mere two weeks could be diagnosed with Major Depressive Disorder,” either using DSM-IV or the proposed DSM-5 draft criteria. Those features alone would not meet the full criteria set required for MDD. The person would also need to meet the “C” criterion [in DSM-IV] of “clinically significant distress or impairment in social, occupational or other important areas of functioning.” Moreover, simply being “sad” does not satisfy the criterion of having “depressed mood most of the day, nearly every day…” for 2 weeks.

Most recently bereaved individuals will not meet full DSM criteria for MDD; do not have a “disorder”; and do not need clinical treatment. Furthermore, there are profound phenomenological differences between ordinary grief and MDD that the experienced psychiatrist will recognize. For example, the ability to be consoled, as Kay Jamison has observed, is typically present in ordinary grief, but rarely in MDD.

That said, many of us believe that the 2-week minimum duration is too short, in most cases, to make a confident diagnosis after bereavement or any other major loss, such as divorce. However, this is irrelevant to the validity of the bereavement exclusion, (BE) and focusing on the 2-week minimum both misses the real point of the debate, and obfuscates the many underlying problems with the BE; e.g., there are no controlled, clinical studies (as contrasted with community survey data) of bereaved, MDD patients to support the BE.

The 2-week minimum is a separate problem that must be addressed separately, and in no way justifies continuing the BE. Leaving the BE in the DSM-5 will not fix the general problem of the 2-week interval. Indeed, elimination of the BE from DSM-5 would also rid us of the bogus, 2-month limit on the duration of “normal” bereavement, for which there is no scientific or clinical basis. Ordinary grief related to bereavement is quite distinct from MDD, and may go on for months or even years; it is not a disorder, nor does it require treatment, if the grieving person functions adequately in the social, vocational, and interpersonal spheres.

I hope that readers will take a look at my upcoming blog on the Psychcentral website, entitled, “Grief, Bereavement, and the DSM-5: How the Public is Being Misinformed.” Also, I have developed a preliminary screening instrument, called the PBPI, aimed at helping clinicians distinguish, phenomenologically, between ordinary grief and MDD. It may be found on the Psychiatric Times website, after a free registration step, under the title, “After Bereavement, Is It “Normal Grief” or Major Depression? The PBPI, A Potential Assessment Tool.”

It is technically not true that “…anyone who is sad, fails to derive pleasure from usual activities, finds it difficult to concentrate, and has sleep and appetite difficulties for a mere two weeks could be diagnosed with Major Depressive Disorder,” either using DSM-IV or the proposed DSM-5 draft criteria. Those features alone would not meet the full criteria set required for MDD. The person would also need to meet the “C” criterion [in DSM-IV] of “clinically significant distress or impairment in social, occupational or other important areas of functioning.” Moreover, simply being “sad” does not satisfy the criterion of having “depressed mood most of the day, nearly every day…” for 2 weeks.

Most recently bereaved individuals will not meet full DSM criteria for MDD; do not have a “disorder”; and do not need clinical treatment. Furthermore, there are profound phenomenological differences between ordinary grief and MDD that the experienced psychiatrist will recognize. For example, the ability to be consoled, as Kay Jamison has observed, is typically present in ordinary grief, but rarely in MDD.

That said, many of us believe that the 2-week minimum duration is too short, in most cases, to make a confident diagnosis after bereavement or any other major loss, such as divorce. However, this is irrelevant to the validity of the bereavement exclusion, (BE) and focusing on the 2-week minimum both misses the real point of the debate, and obfuscates the many underlying problems with the BE; e.g., there are no controlled, clinical studies (as contrasted with community survey data) of bereaved, MDD patients to support the BE.

The 2-week minimum is a separate problem that must be addressed separately, and in no way justifies continuing the BE. Leaving the BE in the DSM-5 will not fix the general problem of the 2-week interval. Indeed, elimination of the BE from DSM-5 would also rid us of the bogus, 2-month limit on the duration of “normal” bereavement, for which there is no scientific or clinical basis. Ordinary grief related to bereavement is quite distinct from MDD, and may go on for months or even years; it is not a disorder, nor does it require treatment, if the grieving person functions adequately in the social, vocational, and interpersonal spheres.

I hope that readers will take a look at my upcoming blog on the Psychcentral website, entitled, “Grief, Bereavement, and the DSM-5: How the Public is Being Misinformed.” Also, I have developed a preliminary screening instrument, called the PBPI, aimed at helping clinicians distinguish, phenomenologically, between ordinary grief and MDD. It may be found on the Psychiatric Times website, after a free registration step, under the title, “After Bereavement, Is It “Normal Grief” or Major Depression? The PBPI, A Potential Assessment Tool.”

Before the DSM-5 Task Force began its deliberations, the idea that normal grief could be a psychiatric disorder would have seemed preposterous. Freud, for example, following thousands of years of psychiatric thought, noted that:
“Although grief involves grave departures from the normal attitude to life, it never occurs to us to regard it as a morbid condition and hand the mourner over to medical treatment. We rest assured that after a lapse of time it will be overcome, and we look upon any interference with it as inadvisable or even harmful.”
Indeed, the notion that grief is a natural reaction to the death of an intimate is so deeply commonsensical that the general definition of mental disorder in the DSM itself uses it as the sole example of a condition that should not be considered disordered: “(Mental disorder) must not be merely an expectable and culturally sanctioned response to a particular event, for example, the death of a loved one.”
There are also good empirical reasons for the bereavement exclusion. One of the causes for the original exclusion in the DSM-III was psychiatrist Paula Clayton’s findings that over 40 percent of individuals who had suffered the death of an intimate would meet the MDD criteria in the absence of the bereavement exclusion. Since Clayton used a one-month, rather than the existing two-week, duration that Pies’ suggestion would entail, a majority of the population could likely be diagnosed with major depression using the current diagnostic standards without the exclusion.
A recent study by Ramin Mojtabai uses prospective data from to test the validity of the bereavement exclusion by comparing the prognosis of bereaved and non-bereaved people who have had depressive episodes. Majtabai’s findings show that three years after the initial episode the rate of depression among the bereaved group (8.2%) was comparable to those who were never depressed (7.5%) but significantly lower than the depressed group that was not bereaved (14.7%). Bereaved people are no more likely than people who are not depressed to have subsequent depressive episodes; the prognosis of bereavement is benign compared to other depressed persons; and grieving people, as Freud predicted, are likely to self-heal without treatment. Providing further evidence for the wisdom of maintaining the bereavement exclusion, Majtabai also found that compared to those with other depressive episodes, respondents with bereavement-related episodes were less likely to have impaired role functioning, psychiatric treatment, or comorbid disorders. These findings are likely to understate the differences between the bereaved and others who met MDD criteria because the latter group included people who met these criteria because of other types of losses. Were this group excluded from the MDD group, the differences between the bereaved and non-bereaved group likely would have been even larger.
So, thousands of years of psychiatric history, common sense, and empirical findings all indicate that grief is a natural response to serious loss, not a mental disorder. Why then, does Pies suggest eliminating the current bereavement exclusion? Because the clinical significance criterion of the MDD diagnosis also requires: “clinically significant distress or impairment in social, occupational or other important areas of functioning.” Therefore, according to Pies, only distressed or impaired grieving people will be diagnosed as depressed in the absence of the exclusion. Pies’ rational is odd: obviously grief involves distress. It is part of our nature as humans to feel intense distress after the loss of a loved one. The clinical significance criterion will do nothing to stop the enormous pathologization of grief that abandoning the grief exclusion would entail.
Pies’ eccentric view flies in the face of empirical research, common sense, and thousands of years of psychiatric history, as well as the definition of mental illness in general and depressive disorder in particular, in every previous edition of the DSM. There is no better illustration of the intellectual bankruptcy of current mainstream psychiatric thought than the fact that the DSM-5 is likely to embrace this view. The general public will justifiably be astonished and scornful of the abandonment of the idea that grief is a natural part of life.

” ‘Common sense’ is the name we give to the prejudices we acquire before the age of 18.” –paraphrase of Albert Einstein

Rather than belabor the numerous logical, scientific, and clinical problems inherent in Prof. Horwitz’s rejoinder, I would refer readers to the extended debate between Dr. Michael First—who shares Prof. Horwitz’s view on the bereavement exclusion (BE)—and Dr. Sidney Zisook and myself. The debate may be found at:

Two brief points of clarification:
1. The debate is emphatically not about whether “grief is a natural reaction to the death of an intimate”; nor is it about whether “normal grief” is a psychiatric disorder. I have never met a psychiatrist who would dispute what nearly everyone who has experienced grief knows: uncomplicated grief is an expected and adaptive response to a major loss, and is not a disorder. Grief, to quote Thomas a Kempis, is one of the “proper sorrows of the soul.” The debate concerns the nature and “internal structure” (phenomenology) of grief, vs. the nature and structure of major depressive disorder (MDD); and whether a bereaved, grieving individual who also meets criteria for MDD, anytime within two months after the death, should be “excluded” from the general class of persons with MDD.
My colleagues and I contend there are no clinical studies—that is, of actual depressed patients—that would support such an exclusion rule, and the 40-year old findings of Dr. Clayton, cited by Prof. Horwitz, are methodologically incapable of validating the bereavement exclusion. Moreover, it is simply circular reasoning to argue that recently-bereaved persons who do meet full symptom and duration criteria for MDD are merely showing “normal grief.” That is precisely the question in dispute! In the debate with Dr. First, Dr. Zisook and I show why the data from Clayton et al do not necessarily show that her bereaved subjects who met 1970s criteria for major depression were simply experiencing “normal grief;” on the contrary, many may have experienced short-lived (lasting a few months) bouts of bona fide major depression.
The kind of carefully-controlled studies needed to validate the BE have simply never been done. The extracted, survey-based data in Dr. Mojtabai’s study—which did not involve clinical evaluation of actual depressed patients, and cannot control for “recall bias”—do not shed light on the populations seen by psychiatrists and other clinicians. The studies of Karam and others—involving real-world, depressed patients—find no substantial differences in bereavement-related vs. non-bereavement-related depression. [see Karam E: J Affect Disord. 2009 Jan;112(1-3):102-10.] The attempt to argue otherwise is part of a long-discredited notion that we can distinguish “depression with cause” from “depression without cause”, or show that “reactive” vs. “endogenous” depressive episodes differ markedly in course, outcome, or response to treatment. [see Kessing L: Acta Psychiatr Scand Suppl. 2007;(433):85-9; Pies R: J Affect Disord. 2009 Jul;116(1-2):1-3. Epub 2008 Dec 4.]. Of course, in carrying out psychotherapy with depressed patients, “cause” and context (including loss) do become very important issues.

2. The debate is not about whether there are flaws in the current or proposed DSM-5 criteria for a major depressive episode—almost certainly, there are. Specifically, the “two week” criterion is not the issue in the debate about the BE. The 2 week duration issue is misleading on several counts.
First, it is extremely rare for a bereaved individual to consult a clinician within 2 weeks of a death of a loved one, unless something has gone very seriously wrong; e.g., the person is suicidal or has developed a psychotic depression. (In those cases, the person often comes in via the emergency room, or is brought in by a worried family member). The BE becomes moot in such cases, since it is not applied when the patient is showing suicidality, psychosis, and other “conditional” features considered markers of serious pathology.
Second, leaving the BE in DSM-5 will not solve the problem with the 2-week criterion, which would apply after any major loss, such as divorce, job loss, etc. My colleagues and I have advocated a longer assessment period (3-4 weeks, in most cases) before applying the MDD diagnosis [see Lamb et al, Psychiatry (Edgmont). 2010 Jul;7(7):19-25.] and I personally favor “tighter” entry criteria for MDD; e.g., expanding the number of required symptoms from 5 to 6 or 7. These issues, however, need to be considered separately from the BE.
Finally, given that suicide rates do not appear to differ between so-called “reactive” and other types of depression [Kessing L, Psychopathology. 2004 May-Jun;37(3):124-30. Epub 2004 May 18], my colleagues and I believe that there is considerable risk in excluding bereaved persons who meet full MDD criteria from the general class of MDD sufferers. When a depressed patient seeks professional help after bereavement, diagnosing MDD does not compel the clinician to begin antidepressant treatment. Rather, the diagnosis of MDD allows and encourages further assessment, and provides the patient with a professional support system, in case the depressive symptoms worsen. If the patient improves spontaneously over the subsequent weeks, no treatment may be necessary. Once again: we do not want to “medicalize” grief; but neither do we want to “normalize” clinically serious depression.

Ronald Pies MD

Note: I am aware of the highly-publicized, recent paper by Wakefield & First in the February 2012 issue of World Psychiatry. There, Wakefield and First argue that existing studies have not “invalidated” the bereavement exclusion, based on several putative methodological flaws in these studies. (“We conclude that the claimed evidence for the BE’s invalidity does not exist.”) I believe that this argument turns logic and scientific method on its head. The burden is for those who want to retain the BE to show that it was valid in the first place; if it was not, then it either needs to be eliminated or validated through appropriately-designed studies. It is emphatically not the burden of critics of the BE to “invalidate” it!

What is ironic is that after decades of scrambling to find ways to establish itself as a legitimate biomedical specialty, psychiatry has done more to damage its public credibility in the last 5 years than I ever would have imagined. Between the very widespread media coverage of the extent of the industry ties so many of its practitioners had or have, the very public news reports about drug companies burying negative study results in order to gain approval for questionable psychiatric drugs, to this. This really caps it all off. The public is watching it all as the controversy is covered by mainstream media outlets. Psychiatry is imploding. It began with its decision to sever the mind and the body so that it could prescribe drugs to as many patients as possible. When it essentially denounced the biopsychosocial model in favor of the higher-paying ‘assembly line’ model (or biomedical, 10-minute med checker model), it triggered a serious of events and a professional ethos that signaled the beginning of the end. Pies et al. and the DSM-5 are yet another nail in the coffin. The more the public sees, the less credibility psychiatry has.

I believe that when sociologists and historians look back on this period of American history, they will conclude that anti-psychiatry invective became one of the last acceptable forms of prejudice in our society.

To be sure, the profession is at a point of crisis, and must be reformed in order to survive–but its obituary has been written prematurely.

Many psychiatrists remain convinced that a holistic and humane approach to the patient does not exclude adhering to the best available scientific studies, which is really the core issue in the debate over grief and bereavement. At the same time, psychiatry must return to its deep connection to psychotherapy and treating the “whole person”, as I discuss in two essays posted on the Psychiatric Times website (a free registration step may be necessary to access these). I hope readers will take a fresh and unbiased look at these essays.

The same movement towards being “at-risk” and therefore, earlier interventions – for the better and the worse – can also be found regarding dementia. This is also true regarding diagnostic categories outside the field of mental health, such as prostate cancer. See for this our article “Neither Body nor Brain: Comparing Preventive Attitudes to Prostate Cancer and Alzheimer’s Disease”, forthcoming in Body & Society.